Provider Demographics
NPI:1609143213
Name:FUNKHOUSER, KELLI (MS, PT)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:FUNKHOUSER
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:371 SILVER OAKS DR
Mailing Address - Street 2:
Mailing Address - City:HARRISONBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22801-3578
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4194 INNSLAKE DR
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-3344
Practice Address - Country:US
Practice Address - Phone:804-217-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-27
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT26509225100000X
VA2305207303225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist